Category Archives: Malaria Corner

The National Malaria Control Program (NMCP) in the Democratic Republic of Congo (DRC) recently reoriented their communication strategy around insecticide-treated nets or ITNs, moving from a focus on behavior change around ITN use to a focus on net care and repair to extend the life of existing ITNs. Why the change?

The 2013-14 DRC Demographic and Health Survey (DHS) showed that only 50% of the household population had slept under an ITN the night before the survey, an indicator they wanted to improve. But when they dove deeper into ITN use, interpreting it in the context of ITN access, a different picture emerged. The survey also found that 47% of the population had access to an ITN. Interpreting these two indicators together, the NMCP redefined their strategy with the understanding that people were using the ITNs they had, and since use was higher than access, more than two people were using each net. In this context, the behavior change messages needed to be targeted toward helping people extend the life of their ITNs.

This kind of data use is only successful when decision makers understand the indicators that are informing their policies and programs. Our new course on K4Health’s Global Health eLearning (GHeL) Center, Measuring Malaria through Household Surveys, dives into the major malaria indicators, guiding learners through the process of collecting and calculating these indicators and through considerations for their interpretation.

The DHS Program has continuously sought to develop tools and curricula to strengthen the capacity of stakeholders to use survey data. From the survey report and dataset to STATcompiler and the mobile app, from tutorial videos to the user forum, and from one-day Data to Action workshops to advanced data analysis workshops, we are always innovating to meet users’ needs.

Last year, The DHS Program developed a Malaria Indicator Trends workshop curriculum to increase the capacity of data users from National Malaria Control Programs to utilize DHS/MIS data to answer key programmatic questions and to accurately interpret trends in malaria indicators. The workshop targets users who needed more information that could be provided in a one-day dissemination workshop but does not have the skills (or need) to analyze with STATA. It was immediately clear that this workshop, which dives into each of the recommended indicators, their calculation, their limitations, and considerations for their interpretation, was meeting a need for data users. The next step to increase the well-informed use of these important indicators was to expand the reach of this curriculum through an online course on the Global Health eLearning Center platform.

This free course targets professionals (both generalist staff working on malaria as well as those with programmatic expertise in malaria) from donor agencies, ministries of health, and implementing and collaborating agencies. It takes 2-3 hours to complete and can be taken as a part of the Monitoring & Evaluation or Infectious Diseases certificates offered through the GHeL center.

When the indicators from household surveys are better understood, better programmatic decisions will be made.

As more countries look toward malaria elimination, the malaria landscape and its measurement are rapidly changing. The DHS Program has adapted its questionnaire and tabulation of malaria indicators to keep up with these changes, which are outlined below.

Indoor Residual Spraying (IRS)

In early 2017, IRS questions were dropped from the household questionnaire.

Why? IRS is typically very focal and done in a small number of districts. National household surveys are not typically sampled to provide representative estimates at this scale. Thus, measures of national IRS coverage from household surveys may not be meaningful.

In the 2016 Liberia MIS, knowing that 1% of households were sprayed in the 12 months before the survey does not tell users about the coverage of the intervention in target areas.

In the most recent questionnaire changes, The DHS Program dropped questions on retreatment of mosquito nets. As a result, tables on net ownership and use in the most recent tabulation plan only have one column for ITNs and do not include a separate column for LLINs. In other words, the ITN column represents nets that are treated with insecticide and no longer require retreatment. This definition is synonymous with LLIN.

Why? Bednets that require annual retreatment and the products used for retreatment are no longer distributed, so the distinction between ITNs and LLINs is no longer meaningful. Differences between values in the LLIN and ITN columns in current ITN tables are minor and likely due to misclassification.

Implications: When looking at trends involving bednets, The DHS Program recommends comparing data from the ITN column over time rather than mixing and matching with the LLIN column from older surveys. Just keep in mind that the definition of ITNs in surveys released before 2018 included nets that had been retreated.

Intermittent preventive treatment during pregnancy (IPTp)

In the past, the table on “Use of IPTp by women during pregnancy” specified that the source of at least one of the doses of SP/Fansidar was an antenatal care visit. Moving forward, the source of IPTp is no longer specified. The question regarding the source of SP/Fansidar will remain in the questionnaire, but it will no longer be presented as part of the standard indicator.

Why? The original language specifying the source of doses was added when IPTp was a new intervention and there was concern that women might report medication taken for treatment of malaria instead of malaria prevention. The intervention is now well known, and this specification is no longer necessary.

Implications: Users should use caution when interpreting trends if the data are pulled directly from the table in the final report. However, the indicator measuring doses of SP/Fansidar regardless of the source can be calculated for past surveys in the datasets and is available in STATcompiler.

During fieldwork for a household survey, survey teams visit households that are selected to represent an entire country. Respondents to the survey are as diverse as the country and live within mountains, valleys, deep in forests, and busy urban centers. These respondents allow survey teams into their homes to answer questions about themselves, their families, and their lives. While I consider myself lucky to have the opportunity to meet and talk to so many people during survey fieldwork, there are certainly many challenges.

For the fieldwork phase of the 2014-15 Uganda Malaria Indicator Survey (UMIS), I spent a day with Patrick, Aziza, Irene N., Doreen, and Persis as they conducted interviews and tested children under 5 for anemia and malaria. Despite the challenges and even some homesickness, the team worked hard to collect data important to Uganda while enjoying the chance to travel throughout their country, make friends, treat children for malaria, and engage with different communities.

Patrick, Lab Technician

“When you test a person’s child and actually find he has malaria, at the end of the day you give them treatment and the guardians are usually grateful. You feel like you’ve helped out.”

Aziza, Interviewer

“It has been hectic. It hasn’t been easy. But at the end of the day we get data, even when you are very tired!”

“I’ve gotten the chance to educate women in the village… This is a way we connect with people in the village.”

Irene N., Interviewer

“Most times, we wake up at 6 so we can be on the road by 7 after breakfast. Then, we get in the field by 8, so each interviewer does 5 to 7 households and then test about 16 children in a day.”

Doreen, Nurse/Interviewer

“We realized that malaria is still a major problem. People are suffering. Young children under five are really suffering from malaria and also anemia.”

“It has actually given us an opportunity to appreciate and learn more about our communities, because you would not have ever imagined that malaria really exists and is killing so many people until you are there, testing and seeing positive rapid diagnostic tests (RDTs).”

Persis, Supervisor

“My motto is, ‘I don’t give up’ … when it comes to work I do it with all my heart. I don’t compromise work, I am really mindful of the quality at the end of the day.”

“I really wanted to work on the malaria survey because health is the first and foremost priority… I believe our work is good.”

The 2014-15 Uganda Malaria Indicator Survey (UMIS) was released on November 6th, 2015, and is the 2nd UMIS as part of The DHS Program. Fieldwork took place from early December 2014 to late January 2015. There were 17 teams for field data collection; each field team included 1 field supervisor, 3 interviewers (1 of whom was a nurse), 2 health technicians, and 1 driver. A total of 5,345 households were interviewed. The 2014-15 UMIS was implemented by the Uganda Bureau of Statistics (UBOS) and the National Malaria Control Programme (NMCP) of the Uganda Ministry of Health.

From October 25-29, 2015, three members of The DHS Program analysis group attended the conference to learn more about the new and innovative ideas emerging in the field of tropical medicine. Some topics of interest include data collection strategies for monitoring and evaluating seasonal malaria chemoprevention (SMC), as well as improvements in malaria diagnostic tools.

While at the conference, three posters were presented by The DHS Program staff:

These three posters were only a fraction of the posters that used or cited DHS data. Many presentations cited DHS data in their background sections and used DHS data in their analysis. Conference attendees also included past DHS workshop participants who continue to use DHS data for their jobs.

In his opening address to the conference, former administrator for USAID Dr. Rajiv Shah commented, “so many of you are drawn to this conference because of your passion to protect those who are vulnerable…to eradicate diseases you know disproportionately affect the poorest communities in the world.” Indeed, the shared passion was tangible and energizing for The DHS Program staff.

If you are interested in tropical medicine, be sure to check out recent DHS analytical reports that use malaria data:

Participants from Nigeria, Uganda, and Malawi work together to interpret malaria data.

Have you ever been to a workshop that combined interactive PowerPoints, fun hands-on activities, malaria indicator trivia games, and lots and lots of data analysis? No? Well then, you haven’t taken part in a Regional DHS/MIS Malaria Analysis Workshop hosted by The DHS Program. The malaria analysis team recently hosted two such regional workshops, one in Tanzania and the other in Senegal, with more than 30 participants representing 13 African countries.

Participants worked in country teams of 2-3 people to answer a pre-identified malaria-related research question through analysis of DHS/MIS data in Stata. While some people might cringe at the thought of an eight day data analysis workshop, in true DHS fashion there was nothing boring about this workshop. Activities throughout the workshops were designed to encompass a range of adult learning techniques – interactive PowerPoints, guided demonstrations, hands-on exercises, and small group activities were all used. The workshops culminated with each team presenting a conceptual framework, key variables, analytic methods, and preliminary results.

Chinazo Ujuju from Society for Family Health in Abuja, Nigeria reflects, “As a researcher I have the drive to analyze available data to provide relevant information for evidence-based public health interventions in my country, Nigeria. Attending the DHS/MIS data analysis workshop has equipped me with the skills to better analyze DHS and MIS datasets using Stata software. I am now competent in multivariate analysis of these datasets. I hope to use my skills to provide information for malaria programming with the ultimate goal of ensuring that relevant information are available to inform policy decisions that would improve global health. “

Though the workshop focused on strengthening data analysis skills, participants also enjoyed the opportunity to collaborate and learn from colleagues from other countries.

Nabila Hemed from the National Malaria Control Program (NMCP) in Tanzania says, “The Regional DHS/MIS analysis workshop has been a wonderful seminar that has brought together professionals of various degrees of experience.The first time I worked with DHS was two years ago. After attending this workshop I learned different issues, limits, and challenges that should be considered during analysis of DHS data. The best part was hearing various country contexts and the effects in data analysis. This helped me understand the impact of research and program decisions during analysis of DHS data. I joined this workshop under the notion that I would simply learn how to analyze to DHS data and how to use Stata. However, I got so much more than what I expected! I received a handful of knowledge and resources that I will definitely use and share with my colleagues at work.”

Participants discuss data use for decision making in a fishbowl discussion session

Though both workshops are complete, country teams are continuing work on their research proposals and abstracts. The DHS Program looks forward to seeing the final products from the workshops in upcoming scientific journals and conferences.

Malaria kills more than 500,000 Africans every year. Consistent use of insecticide-treated mosquito nets (ITNs), early diagnosis and treatment, and prophylactic use of antimalarials during pregnancy can save thousands of lives. But according to the 2011-12 Tanzania HIV and Malaria Indicator Survey (THMIS), many families are not practicing these life saving measures.

To get the message about malaria prevention practices out to Tanzanian communities, The DHS Program collaborated with USAID, the President’s Malaria Initiative, the National Malaria Control Programme, and Media for Development International to produce a film showcasing real life stories of Tanzanians dealing with malaria. Filmed in Dar es Salaam with local actors, Kufa au Kupona (Fever Road), tells three stories. The first is about a young boy who almost dies of malaria because his parents take him to a witch doctor instead of a health care facility when he gets sick. The second story focuses on Jazira who contracts malaria during pregnancy because she does not take IPTp. Five-year-old Brighton, the subject of the third story, is mistakenly treated for malaria when his symptoms are actually due to a urinary tract infection.

Kufa au Kupona (Fever Road)

Kufa au Kupona has been broadcast on 6 national television stations in Tanzania and widely disseminated in high malaria prevalence areas through a partnership with the Tanzania Video Library Association, at health care facilities with video equipment, and through mobile video vans. Now, through an arrangement with FilmAid, Kufa au Kupona will be publicly screened at refugee camps in Africa reaching tens of thousands of people at risk for malaria.

Does Kufa au Kupona have an impact? A follow-up survey of more than 800 women and men leaving the video showings in Tanzania found that virtually all respondents liked the film, and many wished it had been longer. All but two of the respondents said that the film influenced them to take action: 20% said they would get tested for malaria the next time they got sick; 22% said they would use mosquito nets; and 18% planned to discuss the film with other people.

It’s a health risk for more than half the world’s population. A child dies every minute because of it. There are 207 million annual cases worldwide. And 90% of the deaths from this disease (which kills 627,000 globally) occur in Sub-Saharan Africa (source: World Health Organization).

We’re buzzing about malaria. This preventable and curable mosquito-borne illness results from a multiplication of Plasmodium parasites within red blood cells which then burst, causing symptoms that typically include fever and headache. It’s especially dangerous to women and children in Sub-Saharan Africa, where biological, environmental, and socio-economic factors mean a greatly increased risk of malaria transmission. Those at highest risk include children age 6 months to 5 years, who haven’t yet developed partial immunity to the disease, and pregnant women, whose immunity to malaria is compromised.

Invest in the future: defeat malaria. That’s the theme for this year’s World Malaria Day (April 25th). Organizations, governments, communities, and donors have all worked hard to increase access to malaria prevention, diagnosis, and treatment…But there’s still a long way to go. At The DHS Program, we’ve made great strides in collecting and analyzing malaria data for current and future malaria control policy and programming efforts.

The DHS Program collects data in many DHS, SPA, and MIS surveys on a number of malaria indicators, including ownership and use of insecticide-treat nets (ITNs) by children and pregnant women, prevalence and prompt treatment of fever in children, and intermittent preventive treatment of pregnant women (IPTp). In recent years, biomarker testing for anemia and parasitemia has been added, as well as other relevant questions.

DHS surveys with malaria modules have been conducted in more than 30 countries. Ten of these countries have also conducted MIS surveys since 2005: Angola, Burundi, Kenya, Liberia, Madagascar, Malawi, Nigeria, Senegal, Tanzania and Uganda. Find out more on our Malaria Corner.

Population-based malaria survey data are widely used for monitoring and evaluation of programs by international donor organizations, but they remain underutilized by national malaria control programs. In order to strengthen professionals’ capacity in Sub-Saharan Africa, The DHS Program will host workshops later this year in Ghana and Burkina Faso along with partners MEASURE Evaluation, the University of Ghana School of Public Health, and the Research Center in Sante de Nouna (CRSN). These one-week workshops will provide training in effective use of population-based survey data (check back with us in a few months to hear more about the workshops).

3. Analyzing malaria data for research studies.

Members of The DHS Program Analysis team dress up as Indoor Residual Spray (IRS) Sprayers.

The Analysis team at The DHS Program uses the data mentioned in #1 to undertake analytical studies and comparative reports. One such publication is this quantitative, multinational report which discusses preventing malaria during pregnancy in sub-Saharan Africa. This report discusses the determinants of effective IPTp delivery. Though many people tend to think about children and bednets when they hear about malaria, IPTp can be effective in preventing malaria among another high-risk group, pregnant women, but only when administered correctly.

Malariasurveys.org serves as a home to a comprehensive list of malaria indicator surveys, reports, and datasets. It also contains a list of resources on malaria and toolkits for survey implementation and use. This is one of the ways in which The DHS Program partners with Roll Back Malaria (RBM), the global framework designed to implement coordinated action against malaria.

5. Working with the Roll Back Malaria Consortium to help assess the impact of malaria control on child mortality in 15 countries.

The DHS Program also partners with Roll Back Malaria to carry out follow-up nationwide evaluations of the impact of malaria control on all-cause childhood mortality (ACCM) in focus countries over the past decade. These surveys provide updated information on household coverage of ITNs, appropriate diagnosis and treatment of malaria, and prevention of malaria in pregnant women and assess evidence of plausible associations between scale-up of these interventions and reductions in ACCM. The assessments are part of the larger RBM partnership’s evaluation of progress towards the 2015 Millennium Development Goals (MDGs). Learn more about the impact evaluations on the PMI website.

Do you use DHS data to learn about malaria? What’s your favorite malaria-related indicator?

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